NIHB Handbook - First Nations Health Council

PROCEDURE FOR APPEALSAn eligible First Nations person, their parent or guardian may initiate an appeal process whena benefit has been denied through the NIHB Program. There are three levels of appeal available;namely Level 1, Level 2, and Level 3.In order for a case to be reviewed as an appeal, a letter from the individual or parent/guardian,accompanied by supporting information from the provider or prescriber must be submitted tothe NIHB Program. In many cases the service provider will be required to provide part of theinformation being requested. The usual information requested by NIHB is:1. The condition for which the benefit is being requested;2. The diagnosis and prognosis, including what other alternatives have been tried;3. Relevant diagnostic test results; and4. Justification for the proposed treatment and any additional supporting information.The individual or parent/guardian should submit their letter of appeal and supporting documentationby mail, clearly marked "APPEALS-CONFIDENTIAL".Upon receiving the appeals submission, the NIHB Program will arrange to have the casereviewed by the benefit management and medical, dental, orthodontic or vision care professional.The decision will be made based on the specific needs of the individual, medical justification,the availability of alternatives and NIHB policy. The individual or parent/guardian willbe provided with a written explanation of the decision taken by FNIHB-NIHB. If the individualor parent/guardian has not heard within one month of submitting the appeal, they may contactthe Regional Office for an update. (See pg. • for a list of Regional Offices).Where to Submit an Appeal for Drug BenefitsTo initiate an appeal, the individual should submit their documentation, addressed to the NIHBDrug Exception Centre, and mailed to Non-Insured Health Benefits, First Nations Inuit HealthBranch, Health Canada, Postal Locator 1913A, Tunney’s Pasture, Ottawa, Ontario K1A 0L3.If the individual does not agree with the Level 1 Appeal decision, the individual may chooseto have the appeal reviewed at the second level. The submission should be addressed to theDirector, Benefit Management, and mailed to the NIHB Program, First Nations Inuit HealthBranch, Health Canada, Postal Locator 1919A, Tunney’s Pasture, Ottawa, Ontario K1A 0L3.If the individual does not agree with the Level 2 Appeal decision, the individual may chooseto have the appeal reviewed at the third and final level. The submission should be addressedto the NIHB Director General, and mailed to the NIHB Program, First Nations Inuit HealthBranch, Health Canada, Postal Locator 1919A, Tunney’s Pasture, Ottawa, Ontario K1A 0L3.24